Local Coverage Determination For

Local Coverage Determination (LCD): Visual Fields Testing (L34394) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) CGS Administrators, LLC MAC - Part A 15101 - MAC A N/A Kentucky CGS Administrators, LLC MAC - Part B 15102 - MAC B N/A Kentucky CGS Administrators, LLC MAC - Part A 15201 - MAC A N/A Ohio CGS Administrators, LLC MAC - Part B 15202 - MAC B N/A Ohio Back to Top LCD Information Document Information LCD ID Original Effective Date L34394 For services performed on or after 10/01/2015 Original ICD-9 LCD ID Revision Effective Date L31909 For services performed on or after 10/01/2015 LCD Title Revision Ending Date Visual Fields Testing N/A AMA CPT / ADA CDT / AHA NUBC Copyright Statement Retirement Date CPT only copyright 2002-2015 American Medical N/A Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Notice Period Start Date Applicable FARS/DFARS Apply to Government Use. Fee N/A schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not Notice Period End Date recommending their use. The AMA does not directly or N/A indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. Printed on 4/26/2016. Page 1 of 22 UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association (“AHA”), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.” Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Code of Federal Regulations: 42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements). CMS Publications: CMS Publication 100-03, Medicare National Coverage Decisions Manual, Chapter 1: 80.9 Computer Enhanced Perimetry. CMS Transmittal No. 1770, Publication 100 – 04, Medicare Claims Processing Manual, Change Request #6520, July 10, 2009, Medicare contractor annual update of the international classification of diseases, ninth revision, clinical modification (ICD-9-CM). Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Abstract: Visual field testing detects defects in the field of vision, testing the function of the retina, optic nerve and optic pathways. Formal visual field tests are generally performed using automated perimetry, i.e., measurement of the ability to see points of light at varying locations on a curved surface. Indications: Visual field examinations are considered medically necessary for the conditions listed below: 1. The patient has a disorder of the eyelid(s) potentially affecting the visual field(s). 2. The patient has a visual field defect detected on gross visual field testing (e.g., confrontational testing). 3. The patient has a documented diagnosis of glaucoma. It should be noted that the progression of, and effects of treatment on glaucoma can be monitored only through periodic visual field testing. The frequency of such examinations is dependent on changes in intraocular pressure (IOP), retinal damage and changes at the optic disc. Printed on 4/26/2016. Page 2 of 22 4. The patient is suspected of having glaucoma; signs include increased intraocular pressure, asymmetric IOP measurements, notching or thinning of the neuroretinal rim, splinter hemorrhages and asymmetric appearance of the discs. 5. The patient has a documented disorder of the optic nerve, the retina or the neurologic visual pathway. 6. The patient has a recent intracranial hemorrhage, an intracranial mass or a recent increased intracranial pressure measurement (with or without visual symptoms). 7. The patient has a recent occlusion / stenosis of cerebral or precerebral arteries. 8. The patient has a history of a cerebral aneurysm, pituitary or occipital tumor potentially affecting the visual fields. 9. The patient is being evaluated for buphthalmos, congenital anomalies of the posterior segment or congenital ptosis. 10. The patient has a disorder of the orbit potentially affecting the visual field. 11. The patient has sustained a significant eye injury. 12. The patient has unexplained visual loss. 13. The patient has a pale or swollen optic nerve on a recent examination. 14. The patient is having new functional limitations which may be due to visual field loss (e.g., reports by family of patient bumping into objects). (change to e.g.,) 15. The patient is taking a medication with a high risk of affecting the visual system (e.g., Plaquenil). 16. The patient is being evaluated for macular degeneration, or has experienced central vision loss (< 20/70). (Repeated examinations for diagnosis of macular degeneration or central vision loss are not medically necessary unless changes in vision are documented, or to evaluate the results of a surgical intervention). Limitations: Gross visual field testing (e.g., confrontation testing) is a part of general ophthalmological service and should not be reported separately. Other Comments: For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators to process their claims. Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services. For outpatient settings other than CORFs, references to "physicians" throughout this policy include non- physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.) Back to Top Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 011x Hospital Inpatient (Including Medicare Part A) Printed on 4/26/2016. Page 3 of 22 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 071x Clinic - Rural Health 073x Clinic - Freestanding 074x Clinic - Outpatient Rehabilitation Facility (ORF) 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 077x Clinic - Federally Qualified Health Center (FQHC) 085x Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Please note that not all revenue codes apply to every type of bill code.

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